PATIENT / CLIENT INFORMATION

Goodwin Animal Hospital

4701 Atlanta Hwy Mont., AL 36109 / 11485 Chantilly pkwy. Pike Road, AL 36064

334-279-7456 / 334-279-0500

Date ______

Owner’s Name Spouse/Other .

Address City State Zip .

Home Phone Work Phone______Cell Phone______

To establish an account you must be a legal adult 19 or older: DOB: ______

EXPRESS PRIOR CONSENT TO CONTACT CONSUMER BY CELL PHONE PER TCPA (TELEPHONE CONSUMER PROTECTION ACT):

You agree, in order for us to service your account or to collect monies you may owe, Goodwin Animal Hospital, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and agree that Goodwin Animal Hospital, its employees and/or agents may contact me/us as described above.

______
Responsible Party Signature Date

Employer’s Name & Address .

Spouse’s/other’s Employer & Address .

E-mail address: ______

In case of EMERGENCY, please call at telephone number .

Social Security # Spouse Social Security # .

Driver’s License # Spouse Driver’s License # .

FOR IDENTITY THEFT PURPOSES WE NEED TO SEE A COPY OF A VALID PHOTO ID. WE WANT TO TRY AND HELP STOP IDENTITY THEFT BY MAKING SURE THE PERSON WHO SIGNS AND AUTHORIZES SERVICES WITH US IS IN FACT THE ONE WHO SIGNS THIS PAPERWORK.

If you have any additional person(s) that you will allow to bring in, pick up or make any medical decisions for your pet(s) in your behalf please list them below with a contact number. ______

If you have anyone that is NOT authorized to pick up and/or make any medical decisions regarding your pet(s) please list them below. ______

OUR ACCOUNTING SYSTEM IS NOT SET UP TO INVOICE OUR CLIENTS. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. BY SIGNING BELOW, I AM STATING THE ABOVE INFORMATION IS TRUTHFUL AND CORRECT. SHOULD IT BECOME NECESSARY TO FORWARD THE ACCOUNT FOR COLLECTION, I AGREE TO BE RESPONSIBLE FOR ANY/ALL COLLECTION COSTS, SERVICE FEES, ATTORNEY FEES, AND/OR COURT COSTS WHICH WILL INCLUDE A 33.33% COLLECTION AGENCY FEE. I WAIVE NOW AND FOREVER MY RIGHT OF EXEMPTION UNDER THE LAWS OF THE CONSTITUTION OF THE STATE OF ALABAMA AND ANY OTHER STATE.

Any unpaid balance will be subject to a service charge of 1.5% per month, (18% APR). Late charges and additional service charges may also be added under certain conditions.

How did you first hear of our hospital?

Friend or Relative: q Name:______/ Outside Sign: q
Yellow Pages: q / Location: q
Web Search Page: q / Our Web Page: q
Groomer: q / Boarding: q
Used to be client more than 5 years ago: q / Other: q ______

TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED AND BOARDING ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL AND EXTERNAL PARASITES. I AUTHORIZE THE DOCTOR TO PROVIDE VACCINES AND PARASITE CONTROL AS NEEDED FOR MY PET.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.

_____ Please initial here if you give your permission to allow us to publish photographs of your pet(s) on the internet via our webpage or any social media.

______

Signature of Owner Date

____________

Secondary Signature Date


Pet Origin: 1 Humane Society 1 Pet Shop 1 Kennel 1 Advertisement

1 Friend 1 Stray 1 Individual (nonbreeder)

Pet # 1 / Pet #2 / Pet #3
Pet’s Name
Species (cat, dog, other)
Breed
Description (color)
Date of Birth
Age (years)
Sex
Length of time owned
Neutered/Spayed
Vitamins
Diet (kind of pet food)
Any known food allergies?
VACCINATIONS
Name of Former Clinic
Date of DHPP (distemper/parvo)
Date of Bordetella (dog)
Date of K-9 Influenza
Date of Rabies (dog./cat)
Date of Heartworm Test
Name of Heartworm Preventative
Date of FVRCP (infectious disease-cat)
Date of Feline Leukemia
Date of Feline Bordetella
Date of Fecal Exam (worms dog/cat)
Any vaccine reactions?
Prior Illness
Prior Surgery(s)
Dentistry